Exploring Cultural Awareness, Sensitivity, and Competence Script

Welcome

Introduction This course presents an overview of diversity and cultural awareness, sensitivity, and competence. Since it is likely you’ve participated in diversity training at some point in your career, we’ll only discuss the basics of diversity and then dig deeper to explore cultural awareness, sensitivity, and competence. The purpose of this course is to help you, as a healthcare provider, recognize any deeply ingrained prejudices that you may have that can be a deterrent to providing the people you serve with the highest level of care possible. This course will aim to unravel any learned biases you may have developed through life experiences and this course will aim to inspire you to make any necessary changes. This can result in providing your clients with culturally- sensitive care. To help achieve these goals, a variety of self-exploration and culturally sensitive activities are featured throughout this course.

Understand that at times, this course may require you to journey outside of your comfort zone. If you are up for the challenge, then let’s get started exploring diversity and cultural awareness, sensitivity, and competence through self-assessments, reflective questions, case studies, learning interactions, and more.

Objectives After completing this course, participants should be able to:

Identify the types of diversity Recognize the of knowing a client’s Define cultural awareness and sensitivity Describe and its importance within organizations and healthcare providers Recall effective communication techniques to use with diverse clients

Diversity Before becoming culturally aware and competent, it is necessary to first discuss diversity and to recognize that it’s all around us and comes in many forms. In this section, we’ll briefly define diversity, list the abundant types of diversity, and provide activities for further exploring diversity.

What Is Diversity? When we think about diversity we normally just think about race and but let’s expand your definition. Diversity is accepting that each individual is unique, and recognizing individual differences. Its understanding each other and moving beyond simple tolerance to embracing and celebrating the rich dimensions of diversity contained within each individual. The concept of diversity encompasses acceptance, understanding and respect.

Types of Diversity We are different in so many ways. Diversity can be along the dimensions of: Age Gender Race Ethnicity Religious and spiritual beliefs Political beliefs Physical appearance and physical Language Geographic region Socioeconomic background Technological aptitude Literacy/education level

And it’s likely you can think of other types of diversity that are not represented here.

Web Exploration Diversity is widespread and makes up our every day. The next time you visit an online news source, such as CNN.com or Foxnews.com, focus on any cultural differences that are represented on the home page, such as gender, race and ethnicity, religious beliefs, political viewpoints, and so on. Ask yourself if cultural differences are equally represented in the news source. Think about which may be over or under represented.

What Is Culture? Culture refers to a set of shared attitudes, values, beliefs, goals, practices, languages, and so on, that characterizes institutions, organizations, or racial, ethnic, religious, or social groups.

The Value of Knowing Your Client’s Culture Culture can be a useful tool because it’s a source of information. It’s like precious treasure waiting to be discovered. Since culture influences how individuals view their health and the healthcare services they receive, knowing your clients’ culture can help you consider their differences and provide care according to each client’s approach to life.

Knowing everything about each culture is an unrealistic goal; the key is to be aware of basic assumptions, expectations, and behaviors associated with each cultural and within your service area. For instance, it would be beneficial to understand how the groups you work with view healthcare providers, their nutritional preferences, and their religious beliefs and family dynamics in regards to how they make decisions.

The Iceberg Model of Culture We’ve provided the text book definition for “culture,” so let’s now try to understand the concept of culture. One of the most effective ways to illustrate the concept of culture and how it is multifaceted is to use the common “culture and iceberg” analogy. Culture is often compared to an iceberg. Both have a visible structure on the surface and an invisible structure below the surface. An iceberg and culture both have a smaller visible section than invisible section. Their visible section is part of a bigger whole and their invisible section can only be assumed or imagined. The upper portion of the iceberg is represented by the areas of culture which we can simply see, such as dress, language, gestures, behaviors, traditions, and so on. The lower and larger portion of the iceberg is represented by the areas of culture which are not as obvious, such as beliefs, worldviews, motivations, attitudes, communication styles, and so on. Becoming aware of cultural traits that lie beneath the surface can provide us with a more comprehensive understanding of culture. Gaining a cultural understanding is unlikely to happen without exploring deep enough.

A Garden Salad Is the New Melting Pot It’s likely you’re familiar with the melting pot metaphor that has traditionally been used to describe American culture. Social scientists used to refer to the U.S. as a melting pot where new immigrants would be fully integrated into American culture. This has not happened. Modern sociologists disregard the concept of the melting pot and view it as outdated. They choose to adopt the alternate model, which is that of a garden salad. The garden salad represents how immigrants retain their native cultures and mix with other cultures and ethnicities in the U.S. to form a meal where all of the various ingredients are identifiable.

Cultural Awareness and Sensitivity Now that we are aware of diversity and its many types and we’ve thoroughly defined culture, let’s now explore cultural awareness and sensitivity. And in the next section we’ll define cultural competence and its importance within organizations and staff. Before successfully becoming culturally competent, you must first be aware of your own cultural background and behavior and become sensitive to the differences of other cultures.

What Is Cultural Awareness? Cultural awareness requires self-reflection. It is the ability to take a step back and become aware of your cultural views, attitudes, and values. It is the ability to identify your roots and to understand your behavior. You must define your own frame of reference before attempting to relate to those of your clients.

Turn Inward Your experiences and cultural background play a huge role for how and why you think and act. Essentially, your culture impacts your behavior. Since ingrained labels can impact your ability as a care provider, it’s important to look at your own biases, stereotypes and prejudices. To do this, ask yourself questions such as:

Why do I believe what I believe? Why do I react in a specific manner? Where do my biases come from? How can I move beyond them?

Your Influences While you were considering your history and how you may have been influenced to think about people of diverse backgrounds, you may have noticed that there are many different ways that you were influenced. Some important influences may be your: Parents, who are likely the number one influence on how you think about people who are different Teachers and coaches, who may have been your mentors early in life Peers—what your circle of friends think about people with different backgrounds, The news and entertainment media, including radio, TV, movies, advertisements, and the Internet.

All of these can influence what you think about other people.

Cultural Sensitivity Cultural awareness can also signify that you are culturally sensitive, that is, you are aware that cultural differences and similarities exist among you and your clients. You also understand that cultural differences, such as values, behavior, language, communication styles, and so on, can affect your relationships with clients. Think about this: If you are insensitive, how uncomfortable are you making your clients? Cultural awareness and sensitivity requires you to be open and flexible with others’ values, beliefs, and perceptions. This will help to expand your clients comfort level. It is essential to recognize that everyone sees things differently and what one considers normal and acceptable can be unacceptable to others.

Interlock Hands Try this quick exercise. Interlock your hands. Look at how you have interlocked your thumbs. Most people put their left thumb on top. Now, change your grasp so that your opposite thumb is on top. How does that feel? Uncomfortable? Different? This is because it is not what you know or are used to. Just like with diversity, different can be uncomfortable. Accepting discomfort and understanding the differences between people is what valuing diversity is all about.

Benefits of Awareness and Sensitivity Practicing cultural awareness and sensitivity helps to avoid possible misinterpretations when working with others. Developing awareness and sensitivity can help you understand, communicate with, and effectively interact with your diverse clients. It can result in an appreciation that we are all different, a realization that our similarities and differences are both significant, and an acceptance that there are many ways to accomplish a goal.

Stages of Cultural Awareness Here are the four stages of cultural awareness that reflect a person’s progression towards recognizing and accepting cultural differences. Click the marker on each level of the triangle to learn about each stage of cultural awareness. Start from the bottom of the triangle and move upward. As you explore each stage, consider which stage you’re currently in and what you could do to advance to the next stage. When you are finished, click next to continue.

Parochial Stage At the first stage, you are unconsciously unaware of cultural differences and lack any understanding of . You are aware of your own cultural worldview and do not believe other cultures exist. Essentially, you are aware of the way you do things and think your way is the right and only way. Ethnocentric Stage At the second stage, you are consciously aware there are other cultures, but you consider yours superior to others. Similarly, you recognize there are other ways of doing things, yet you still consider your way is best. In this stage, you realize differences exist, though you understand very little about what these differences are. You view cultural differences as a problem, yet you’re unsure of the significance of the problem and you tend to ignore the problem. Synergistic Stage At the third stage, you have knowledge of cultural differences and practices and you believe these differences can be valuable. You are now able to choose the best way to do things, whether it is your way or others’ ways. Culturally-appropriate behavior does not come naturally yet, so you make a conscious effort to behave properly. You are aware of how your behavior is perceived by others and you are working on substituting old habits with new ones. Participatory Third Culture Stage: At the fourth stage, you unite with other cultures to create a culture of shared meanings and new rules to meet the needs of a situation. Since you’ve been transformed by a new culture, you instinctively do the right thing and it takes little effort for you to be culturally sensitive.

What Is Cultural Competence? Cultural competence is a set of behaviors, attitudes, and policies that enable organizations and staff to work effectively in cross-cultural situations. Within this definition, ‘competence’ implies having the capacity to function effectively as an individual and an organization within the context of your clients’ cultural beliefs, behaviors, and needs. (Adapted from Cross et al., 1989).

Why Is Cultural Competence Important? Cultural competence is an essential element to help eliminate inequality in the healthcare setting. In the United States, the number of cultural and ethnic groups is increasing among clients and healthcare providers. Therefore, you may be confronted with the intimating responsibility of providing equitable and quality care to your clients from different backgrounds. Culturally competent organizations, agencies, and professionals directly impact the level of care clients receive and can prevent challenges caused by diverse backgrounds and health disparities. The result of culturally competent providers is better diagnoses, appropriate treatment plans, and client compliance to treatment plans. Overall, cultural competence may help to promote more positive health outcomes and satisfied clients and families.

A Culturally Competent Organization A culturally competent organization establishes policies and practices that accept and respect differences, evaluates and improves its cultural knowledge and resources, and changes policies and practices to meet the needs of its clients.

Competent Organizations The following elements can contribute to an organization’s ability to develop cultural competence: First, the organization must value diversity. Second, the organization must have the capacity for cultural self-assessment. Third, the organization must be conscious of the dynamics inherent when cultures interact. Fourth, the organization must have institutionalized cultural knowledge. Fifth, the organization must have developed adaptations of service delivery reflecting an understanding of cultural diversity.

Cross et al. (1989) Understand that cultural competence is an ongoing process and requires continual evaluation of your organization’s policies, practices, and attitudes.

Culturally Competent Providers Becoming culturally competent is an evolving process and is similar to developing other skills and professional credentials. With training, practice, and commitment, you can acquire cultural competence and provide quality services. As a culturally competent healthcare provider, you:

Understand that your clients’ culture affects their beliefs, values, and behaviors. View your clients as unique individuals. Appropriately respond to the varied cultural needs of your clients. Build a strong trusting relationship with them. Avoid cultural differences that might hinder interactions and discussions with your clients. Accept that being culturally competent is more than being culturally aware and sensitive.

For example, if you are culturally competent, your abilities might range from helping your client find their way around the facility to communicating in a way that allows your client to give meaningful consent to services provided.

Culturally Competent Care Provide culturally competent care by being sensitive, aware, and respectful towards your client’s:

Pain – Accept what your clients say to you about their level and frequency of their pain. Regardless of culture, pain is subjective.

Family Dynamics –Recognize and honor how families function according to their culture. This can include finding out which family member(s) to give information to, and with whom to consult with regarding decision making.

Grief – Respect the rituals or practices that are important to your clients when death is near or has occurred. The grieving process is different for each person and each culture.

For additional questions to consider when caring for your clients, download the attached document from the resources tab of this course player.

Effective Communication Since language barriers and miscommunication are common hurdles in the healthcare industry, communication has proven to be one of the most important skills you can master. In this section, we’ll discuss a few effective communication tactics to help avoid misunderstandings.

Ask Questions Learn about your clients’ cultural background. To do this, ask your clients to share something about their culture, beliefs, or practices that would help you provide them with quality care. Let’s take a look at a case study to see how this approach could work in a real-life scenario.

Case Study Hong is an Asian male who is being treated for HIV. Hong and his family distrust healthcare practices and healthcare providers, and they believe in the use of traditional therapies to treat illnesses. Because of Hong’s cultural beliefs, he is using herbal remedies instead of the antiretroviral therapy the healthcare center had prescribed. Deena is Hong’s nurse at the healthcare center. What actions might she take to provide more culturally competent care?

Could she engage Hong and his family in a dialogue about their distrust of healthcare providers and the possible source of that distrust? Could she obtain more information about the traditional herbal remedies Hong is using and his understanding of what each herbal remedy is doing? Could she investigate treatment alternatives that combine eastern and western elements?

Verbal Communication Verbal communication refers to the use of words to relay a message. Here are a few approaches that can help ensure your clients are well-informed and are able to rightfully accept their care. When working with clients with limited English: Speak slowly and in simple sentences. Do not repeat words or speak louder. Provide information in the appropriate languages (including ).

Similarly, if you speak with a foreign accent, clearly enunciate your words, specifically when addressing a client who may not be familiar with certain accents.

Use People First Language Value a person through people first language. People first language is using appropriate language that places the person before the . The words used about a person impact them and can lead to the person feeling segregated and depreciated. Because of this, it is important to create positive change in the people you serve. To do this, implement good manners and respect while communicating with your clients, be aware of how you choose your words, and aim to promote positive outlooks. Mark Twain noted, "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Now, let’s get some practice recognizing people-first language.

Nonverbal Communication refers to the use of body language to relay a message. Nonverbal cues are important to understand to help prevent sending wrong messages to your clients. When interacting with your clients, allow them and their families to take the lead and to set the tone for what they determine acceptable or unacceptable cues.

Types of Nonverbal Communication Click on the markers to learn about some examples of differences in nonverbal communication that likely lead to misunderstandings. When you are finished, click next to continue.

Eye contact: In some cultures, evading eye contact can be interpreted as disinterest. In other cultures, avoiding eye contact can be considered respect for authority or the elderly.

Touch: Some cultures forbid touching between different ; some cultures believe the head to be sacred and should not be touched unless given permission; and some cultures consider touch as comforting.

Voice: Some cultures consider speaking loudly as disrespectful. Similarly, some cultures prefer formal interactions and dialogue while others prefer informal interactions.

Personal space: For some cultures, an arm’s length away is a comfortable distance when talking with others, but in other cultures people may stand much closer.

Gestures: The meanings of gestures vary throughout cultures. For instance, the American culture nods the head to indicate agreement or understanding, but other cultures nod to show respect.

Avoid Specific Gestures Some gestures that are acceptable in one culture can be considered offensive in another. For instance, you’ll want to avoid these common gestures that have conflicting interpretations across cultures:

The “Come here” gesture using the pointer finger. In the Philippines, this gesture is a method of communication considered worthy only to use on dogs and using this gesture can get a person arrested.

The “O.K.” sign using the thumb and pointer finger. In the U.S. and the UK, this sign is generally called the “A-OK” sign and indicates all is great or fine. In other cultures, it is considered obscene and denotes an insult.

The “Thumbs up” sign. In , this sign generally indicates a job well done, while in other cultures it means the same as giving the middle finger.

The V-Sign with the palm facing outwards or inwards. In the U.S. both directions mean the same thing – victory, or peace and love. In other cultures, it denotes an insult if the palm is facing inwards (with the outside of the hand facing the person).

Case Study Let’s walk through this case study to see how effective communication could work in a real-life scenario. Two years ago, Suzanne, a healthcare provider, started providing services to Simon, a member of the Deaf community. Even though he had an interpreter who signed to him so that he could communicate with Suzanne, Suzanne and Simon never seemed to form a bond. Because of this, Suzanne was overly stressed and unable to feel confident with the level of care she was providing to him. Then one day, Simon brought a new interpreter with him, named Becky. And on this groundbreaking day, Suzanne learned that after all of this time, she and Simon never connected because she wasn’t communicating with him, at all – Suzanne was interacting directly with the interpreter. What this means is that as she spoke, Suzanne postured her body towards the interpreter, she made eye contact with the interpreter, she gestured to the interpreter…she directed all of her verbal and non-verbal communication to the interpreter. Then on that day, Becky said to Suzanne: “Please include Simon in the discussion. To do this, direct your conversation to him. Face him and speak directly to him. He can read your lips.” After developing the insight for how to effectively communicate with Simon, Suzanne immediately saw him responding in a positive manner. Suzanne became aware that she was excluding Simon and viewing his deafness as a handicap, which made him feel limiting. And she now realizes that he views his deafness as a shared experience underlying his sense of community. Since that day, Simon and Suzanne have established a respectful relationship which improved the quality of care that Simon receives. Suzanne can’t thank Becky enough for the valuable learning experience and for opening her eyes to an authentic approach for communicating with Simon.

Case Study: Reflection Questions Based on the outcome of Suzanne and Simon’s story, take a few moments to reflect on these questions: Can you think of certain tasks that may now be easier for Suzanne to accomplish? How do you think Simon feels when he interacts with Suzanne? Might he feel empowered instead of feeling limited? How might Suzanne’s attitude toward working with Simon have changed? Might she be less stressed knowing she is providing Simon with the highest level of care possible? Can you think of any other possible outcomes that may impact their relationship and the level of care provided?

Create Change Your ‘Beliefs’ determine your ‘Attitude’ and your ‘Attitude’ determines your ‘Actions’. So it’s important to look at your long held beliefs and be open to making some changes, otherwise you can’t change your actions. Once you truly believe that all people have value, each with their own gift to share – your attitude will shift and your actions will follow. Changing your beliefs about our differences is where you start – changing your behaviors is where you end up. The process of taking action to create change begins within you and then extends to influence others. We all have beliefs and attitudes about culture, race, gender and ethnicity which include or exclude others. By taking a hard look at these we can each begin to make the much needed changes within our lives, our workplace and our society as a whole.

Bridge Cultures Once you recognize diversity and practice ways to become more culturally aware and competent, then you can start to connect cultures. Here are a few attitudes to help you bond with your diverse clients:

Admit that you don’t know. It’s OK to say, “I don’t know” or “I may be wrong, but…” Admitting that you don’t know everything and that your assumptions may be inaccurate is part of becoming culturally aware.

Refrain from making judgments. Before evaluating a situation or person, try to gather substantial information so that you can accurately describe the situation.

Be empathetic. Vicariously experience your client’s feelings, thoughts, or attitudes in order to understand that person. The goal is that, through empathy, we learn of how our clients would like to be treated.

Control your assumptions. Ask your coworkers for feedback on how you handled a specific situation and regularly check your assumptions to make sure that you clearly understand the circumstance and its context.

Become comfortable with ambiguity. Accept that others can teach you and that their way can add to what you know. Personal growth is more likely to develop if cultural perspectives are flexible.

Celebrate diversity. Using your own personal approach, find ways to celebrate diversity.

Practice Interpersonal Skills Providing services to a group of diverse people requires interpersonal skills. It is likely that these communication competencies can help to promote effective communication in a diverse setting. As a healthcare provider: Listen actively and nonjudgmentally. Challenge your concepts about diversity. Practice conflict resolution and change management skills. Be sensitive toward terms labeling groups regarding diversity. Identify diversity issues and understand related tensions. Express respect and appreciation. Be open to learning about others who are different.

Did You Know? As we approach the end of the course, let’s learn a few fun facts about people around the world. Pay attention to broken stereotypes, surprising facts, and differences in communication styles. And think how unexpected realities can also exist within the people you serve.

Alexander Graham Bell invented the telephone and his wife and mother were both members of the Deaf community.

Fortune cookies are an American invention that originated in , but there has been much debate surrounding who the actual inventor was and which city in California the cookie was created.

The Navajo Indian language was used to communicate codes and secret messages by the US in WWII.

There are over approximately 300 religions and denominations in the United States.

St Patrick, the patron saint of Ireland, was not Irish. It is known that he was born in Britain and captured there by Irish raiders who then transported him to Ireland.

In Tibet, it is considered polite for Tibetans to briefly extend their tongues as a greeting. Tibetans also stick out their tongues to show agreement and respect.

Want to Learn More? If you are interested in this topic and would like to learn more about different cultures, see the link in the resources tab labeled “Exchanges Connect,” in the resources tab of this course player.

This site is managed by the U.S. Department of State’s Bureau of Educational & Cultural Affairs.

Though this international online community connects cultural exchange program participants, it is a great resource for learning more about culture. Specifically, the featured stories describe participants’ cultural challenges and surprises, changing viewpoints, and cultural commonalities when living in their host country. Additionally, participants share their stories by featuring videos that illustrate memorable cultural moments.

Summary In summary, this course presented an overview of the types of diversity; the value of knowing a client’s culture; the importance of cultural awareness, sensitivity, and competence; and effective communication techniques to use with diverse clients. It is hoped that this course inspires you to recognize any deeply ingrained prejudices that you may have, unravel those learned biases, and make any necessary changes in order to provide your clients with the highest level of care possible.